Student - Athlete Registration Form

To provide sport training and competition to people with an intellectual disability

Upon completion of this form a copy will be forwarded to the individual completing it

Please indicate your e-mail address below:

NOTE: This is a School Board authorized Registration Form distributed by Special Olympics Ontario (SOO), a non-for-profit charitable organization. This form must be completed by a parent/caregiver. The information collected will only be used by SOO for SOO related activities.

Does your child have an intellectual disability and a physical disability?

(A physical disability is identified as having closely related developmental disability with functional limitations in both general learning and adaptive skills; but the functional limitations are only due to: physical disabilities, emotional disturbances, behaviour disorders, specific learning disabilities, visual impairments, or sensory disabilities.)

YesNo

ATLANTO-AXIAL INSTABILITY PROFILE

Individuals who have Down Syndrome that have been tested positive for Atlanto-Axial Instability, shall not be permitted to participate in sport training and competition which, by their nature, result in hypertension, radical flexion or direct pressure on the neck or upper spine. Such sports training and competition activities include, but are not limited to: butterfly stroke and diving starts in swimming, pentathlon, high jump, powerlifting, artistic gymnastics, basketball, soccer, alpine skiing and any warm-up exercise placing undue stress on the head and neck.

Does your child have Down Syndrome?

YesNo

Date of last X-Ray
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MM
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DDYYYY

X-Ray Result

PositiveNegative

For more information and a copy of the Atlanto-Axial Examination form, contact your class teacher or visit our website at http://www.specialolympicsontario.com

ATHLETE, CAREGIVER, GUARDIAN OR PARENT RELEASE

Athletes under the age of 18 must have a caregiver/legal guardian sign this release on their behalf.

I, the undersigned athlete (caregiver and/or legal guardian), hereby request permission to participate in the Special Olympics Canada Inc. program. I represent and warrant you that I am physically able to participate in Special Olympics Canada, Inc. I acknowledge that I will be using facilities at my own risk, and I hereby release, discharge and indemnify Special Olympics Canada Inc. from all liability for injury to person or damage to property of myself. As a participating athlete, I am specifically granting permission to Special Olympics Canada Inc. to use my likeness, voice and words in television, radio, film, newspaper, magazines and other media, and in any form not heretofore described for the purpose of advertising or communicating the purposes and activities of Special Olympics Canada and in appealing for funds to support such activities. I agree to abide by the Special Olympics Canada Inc. rules, policies, procedure and Code of Behavior. If I am unable to be consulted in case of necessity, Special Olympics Canada Inc. is authorized at my account to take such measures and arrange for such medical and hospital treatment as is deemed advisable for my health and well-being. Any and all references to Special Olympics Canada Inc. include and apply equally to Special Olympics Ontario Inc.

Can your athlete's photograph be used for media purposes as mentioned above?

YesNo

* I agree to abide by the Special Olympics Canada Inc. and Special Olympics Ontario Inc. rules, policies and procedures and Code of Conduct.

* I affirm that I have read the above release and that the information I have given is true and complete.

Type your full name to verify your understanding of the above statements: *